sternal plates post CABG

TennRN2004 · Aug 10, 2006

Anyone out there familiar with the use of sternal plates being used in addition to figure 8 wiring post CABG? What is the healing time? Are they supposed to click and clack like the tin man afterward and if so, for how long?

A sternal plating will be used if the patient is a redo and has an unstable sternum, or if the surgeon is worried about the sternum healing without the plating being used. Example, an obese diabetic patient with IMAs used, you worry about the integrity of the sternum in this type of patient for several reasons-diabetes and IMA use can cause poor wound healing since good oxygenated blood flow may not be getting to the sternum causing increased risk of infection, and depending on how obese the patient is, there is always possibility of wound opening up, obese patient on top of patient at high risk for infection increases chances of problem with wound, so the sternal plate will hopefully prevent numerous complications. Healing time will vary based on number of things just like any other bypass patietn-health prior to surgery, length of time in hospital prior to surgery (increased LOS in hospital will increase exposure to nosocomial bugs), patient hx-vascular problems, diabetic, smoker, antibiotic coverage, surgeon, good post op wound care, and a lot more but that is a rough start.

As far as a clicking, you may hear a large pericardial rub because there is inflammation of the pericardium. I'm not sure what other type of clicking you have heard, but valve patients can also have a click noise if a mechanical valve is used. Also, if the patient is thin, poorly nourished, has little fat tissue, or loses a lot of weight, a rub may occur.

momdebo, BSN, RN · Aug 11, 2006

Thanks for the reply, little background, pt was not obese, not diabetic, not emaciated. CABG was performed d/t failed cardiac clearance for aaa repair, ST was +, resulted in cath that showed multivessel disease, hence the CABG. Pt had a severe cough, almost looked like reactive airway problem, one PA saw it and got ready to code the pt, no ectopy noted during coughing so it was strictly pulmonary. It really didn't sound like any kind of rub. Really sounds like metal clacking together. on x ray there was a perpendicular plate at the superior end of the sternum, 2 horizontal plates on inferior sternum, and yes, have to say, it really sounded like metal clacking together, could hear this without a stethoscope, just sitting there, the pt would move or cough and then I would hear this clacking. pt states is about ready to lose his mind listening to it. I've never dealt with anything like this so I really didn't know what to counsel on.

TennRN2004 · Aug 11, 2006

Hmmm...well sorry I guess my post wasn't much help. I haven't seen anything like you are describing. We see sternal plating very infrequently, and usually only for the reasons I posted. I am unclear what made sternal plating necessary in this patient. I would read the op note to see if surgeon made note of why plating was used (ours always do). I don't know how your relationship is with your surgeons, but I would also ask when they rounded about what is normal to expect with plating and point out your concerns. I personally have never seen any ours plated with what you are seeing, I admit I would be concerned enough probably to put a call in and ask MD or thier RN covering, but most of ours would not mind such a call as long as it wasn't 3 am in the morning. I would also ask my co-workers if any of them had seen something like this before. Have any of your fellow nurses given any other ideas on that patient?

momdebo, BSN, RN · Aug 12, 2006

Hi TennRN2004, your post was very helpful, I know next to nothing about this sternal plating technology. Sorry if my post was confusing. This pt. was one week post CABG and actually fractured his sternum by coughing, the cough was so strong d/t underlying lung disease that he fractured the sternum in 5 places, the incision became 80% unzipped and actually busted 2 of the wires holding it together! docs told me they have only seen this happen one other time before in all the CABG's they have done. The answers I have recieved from the surgeons regarding healing, the audible clicking of the metal plates, etc. have all been very vague, almost like they aren't quite sure themselves. so I thought I would throw this out there to all you folks, the nurses on here are a wealth of knowledge, thought maybe someone might have seen or heard of this kind of thing since it is pretty rare according to the docs. thanks again for your input:D

TennRN2004 · Aug 14, 2006

Wow, it does sound like this was an extreme case. I would be concerned about the clicking from the plating, b'c I honestly don't think it is a normal finding. But, with the pts severe injury, maybe over time as he heals it will go away. I would hate to guess in such a pt how long the healing time would be, but hopefully the plating will protect the sternum so he can heal properly and not have any more issues. I'll ask one of our docs next time I work and see if they've ever seen a case like this. We only do the sternal plates few and far between though.